10 Questions: Howard K. Mell, MD, MPH

If you could change something about the healthcare system, what would it be? That's just one of the 10 questions the MedPage Today staff is asking clinicians, researchers, and leaders in their community to get their views on their chosen profession. Here, responses from Howard K. Mell, MD, MPH, spokesman for the American College of Emergency Physicians.

Mell received his medical degree and master of public health degree from the University of Illinois at Chicago. He completed his residency in emergency medicine at the Mayo Graduate School of Medicine in Rochester, Minn. For 8 years before his medical training, Mell was a firefighter/paramedic in the suburbs of Chicago. He serves as a clinical assistant professor in the department of surgery at the University of Illinois at Urbana-Champaign. He is also the EMS medical director for the Newark division of fire in Ohio. Mell works for a national physician staffing company in a variety of community emergency departments throughout the Midwest.

1. What's the biggest barrier to practicing medicine today?

As an emergency physician, one of the biggest barriers to practicing medicine is my patients' lack of access to primary and specialty care. Some of my patients need follow-up for conditions that, while not complex enough to warrant admission to the hospital, require more treatment than I can provide in the emergency department (ED). Often, there are no primary care physicians to provide or coordinate this care. Other times, specific specialties, such as hand surgery or gastroenterology, are not present in a community. Lately, this issue is further complicated by physicians opting out of Medicare/Medicaid or not being "in network" for exchange insurance policies.

2. What is your most vivid memory involving a patient who could not afford to pay for healthcare (or meds, tests, etc.) and how did you respond?

An inability to pay for medications is a frequent problem in the ED. Some antibiotics are clearly indicated as the best choice for certain conditions, such as Augmentin [amoxicillin/clavulanate potassium] or clindamycin to treat infections from animal bites -- both are expensive. It seems like I get at least one phone call from a pharmacy each shift asking to change a medication due to cost. Unfortunately, there is not always a good alternative. I can remember one little girl with an early infection on her cheek from a cat bite. Her parents delayed bringing her into the ED due to cost concerns. She was a "self-pay" patient, and the ED staff knew there was no way her family could afford the needed medication. I was friendly with the night manager at a local pharmacy. We took up a collection and paid for most of the medication for her. I don't think her family ever realized that the medication cost a lot more than the $4 they were charged.

3. What do you most often wish you could say to patients, but don't?

I wish I could align patients' expectations of what medicine can do for them with the reality of our capabilities.

4. If you could change or eliminate something about the healthcare system, what would it be?

I would make all medical education tuition free. Having physicians finishing residency $500,000 in debt is not a sustainable model. This indebtedness dissuades some fantastic students from a medical career and pushes others out of primary care and into more lucrative subspecialties. These costs are passed down throughout the system.

5. What is the most important piece of advice for med students or doctors just starting out today?

Medicine is a team sport. Listen to your teammates -- you can't do it alone.

6. What is your "elevator" pitch to persuade someone to pursue a career in medicine?

I don't have one. Being a doctor is the best job in the world, but it is a calling. In my opinion it is far less important to persuade someone to pursue a career in medicine than it is to support someone who already has the desire.

7. What is the most rewarding aspect of being a doctor?

Emergency physicians get to be present for every aspect of life. We see people from cradle to grave, and at their most vulnerable moments, whether the person is our patient or a family member of our patient. That is often awe-inspiring. Yesterday, we worked unsuccessfully to save a man from cardiac arrest. His wife of 50 years held his hand as he died. The next patient I saw (once I dried my tears) was a 4-month-old with a cough. She was fine, adorable and smiling, with two young, extremely nervous, doting parents and grandparents in tow. A little reassurance and all was well. What other job lets you be a part of all that?

8. What is the most memorable research published since you became a physician and why?

The work being done by PECARN, the Pediatric Emergency Care Applied Research Network, is absolutely wonderful. PECARN is the first federally funded pediatric emergency medicine research network in the U.S. PECARN conducts high priority, multi-institutional research on the prevention and management of acute illnesses and injuries in children and youth of all ages. As a clinician, these studies are wonderful because most of them -- such as Childhood Head Trauma/Neuroimaging Decision Rule -- are designed to provide physicians with data to determine the risks of specific outcomes in treatment settings. In other words, this patient has a one in 5,000 chance of having a clinically significant brain injury and the risk of empiric treatment or testing is one in 1,000. This allows a discussion with patients to be framed properly, i.e., 'I can't say for certain your child doesn't have a head injury, but if we do a head CT, we are statistically more likely to hurt him than we are to help him.' PECARN excels at research that is patient-centered and applicable in the real world.

9. Do you have a favorite hospital-based TV show?

I have loved watching "Emergency" since I was a kid. Now I watch them on DVD.

10. What is your advice to other physicians on how to avoid burnout?

The advice is simple to suggest, but hard to follow: Do what you love and love what you do -- and keep a healthy balance between your career and the rest of your life.

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